A review of the oral health status in Syria

AIM: To estimate the prevalence and severity of dental caries and periodontal diseases in Syria and to determine possible secular changes in the last two decades. METHODS: Epidemiological studies performed between 1980-1999, using the WHO criteria for dental caries and the CPITN criteria for periodontal diseases in Syria were retrieved and reviewed. RESULTS: The caries experience of 5-year-old children was high (dmft of 4.7-5.2). The estimated DMFT score of 12-year-old Syrian children was 1.9-2.3. A secular change of the caries experience in the last two decades was not apparent. The amount of untreated caries lesions was high and had not changed substantially in the last two decades. The D component comprised 72-90% of the DMFT of 12-15-year-old children and 26-30% of the DMFT of 35-44-year-old Syrians. The majority of 15-24-year-olds, and more than 80% of the 35-44-year-olds had calculus. Despite the widespread and chronic existence of calculus, only 3-11% of the 35-44-year-old persons had one or more deep periodontal pockets. CONCLUSION: The caries experience in Syria is moderately low and does not seem to have changed in the last two decades. The increased output of graduate dentists in the last decade has not changed the large amount of untreated caries lesions. In Syria, where the prevalence of unmet (caries) treatment needs is high, regular removal of calculus (scaling) for the sake of preventing periodontal pockets should not have a high priority in the oral health services.     

The second national survey of oral health status of children and adults in China

OBJECTIVES: To describe the oral health status of Chinese children and adults at national level in relation to location and province and to highlight changes in dental caries experience. DESIGN: Cross-sectional study, oral epidemiological survey based on WHO methodology, clinical examinations. SETTING: National survey by National Committee for Oral Health. SUBJECTS: Representative samples of provinces, districts, townships; cluster sampling including subjects aged 5,12,15,18, 35-44 and 65-74. Each age group consisted of 23,452 participants, i.e. total of 140,712 individuals. RESULTS: At age 5, 76.6% were affected by dental caries and mean dmft was 4.5. Mean DMFT varied from 1.0 in 12-year-olds, 1.4 in 15-year-olds, 1.6 in 18-year-olds, 2.1 in 35-44-year-olds to 12.4 in 65-74-year-olds. In adults, caries experience was higher in females than in males. The effect of urbanisation on caries prevalence in children varied by province and age. Among adolescents and young adults caries levels were high in urban areas while caries experience was high for old-age people of rural areas. At national level, changes in dental caries prevalence of 12- and 15-year-olds were small. However, some provinces with extensive oral health programmes (e.g. Love Teeth Day) showed declining caries experience whereas provinces with limited preventive activities had increasing levels of caries. For all age groups, gingival bleeding and calculus were most frequent. Severe periodontal conditions were relatively rare. CONCLUSION: The systematic implementation of preventive oral care and community-oriented health programmes are needed for the continuous promotion of oral health in China.     

Oral health status of children and adults in urban and rural areas of Burkina Faso, Africa

OBJECTIVES: To analyse the oral health status of children and adults in rural and urban areas of Burkina Faso; to provide epidemiological data for planning and evaluation of oral health care programmes. DESIGN: Cross-sectional survey including different ethnic and socio-economic groups. SAMPLE AND METHODS: Multistage cluster sampling of households in urban areas and random samples of participants selected based on the recent population census in rural areas. The final study population covered four age groups: 6 years (n = 424), 12 years (n = 505), 18 years (n = 492) and 35-44 years (n = 493). Clinical oral health data collected according to WHO methodology and criteria. RESULTS: At age 6, 38% of children had caries, with prevalence higher in urban than rural areas. At age 12, the mean DMFT was 0.7 with prevalence significantly higher among urban than rural children. Mean DMFT was 1.9 in 18-year-olds and 6.3 in 35-44-year-olds and figures were higher for women than men. In adults, no differences in caries experience were found by location whereas the caries index was significantly affected by ethnic group and occupation. CPI score 2 (gingivitis and calculus) was dominant for all ages: 6 years (58%), 12 years (57%), 18 years (58%), 35-44 years (49%). In addition, 10% of 35-44-year-olds had CPI score 4. Rural participants had more severe periodontal scores than did urban individuals. CONCLUSIONS: Health authorities should strengthen the implementation of community-based oral disease prevention and health promotion programmes rather than traditional curative care.     

Oral health and dental care in modern-day China

The purpose of this paper is to present salient background information on the oral care situation and organization in China and to review epidemiological literature that has been published on adults in Chinese dental journals during the last 20 years as a context for understanding ongoing oral health research activities in China. Searches were conducted through Medline as well as Chinese language catalogues and around 30 Chinese dental journals. Most oral health surveys on adults were conducted after 1970 mainly on residents living in big cities, which are also the location of major medical universities. Surveys conducted among farmers were uncommon. Dental caries and periodontal disease were the major dental diseases studied. Only a few surveys on people's oral health knowledge, attitudes and behavior were conducted. Papers concerning dental treatment needs and utilization of dental services among adults were scarce. Sample size was usually not a major problem in these surveys but the sampling methods and diagnostic criteria used were often poorly defined. Mean DMFT scores between 2 and 6 were reported in the 35-44-year-olds and between 9 and 16 in the elderly younger than 75 years. Calculus and gingivitis were reported to be common in adult Chinese; the proportion of subjects with shallow and deep periodontal pockets was not high. Complete edentulousness in the 60-69-year-olds was usually reported to be less than 10%. About 14% of the 35-44-year-olds and 19% of the 65-74-year-olds did not brush their teeth daily.     

Oral health status of children and adults in the Republic of Niger, Africa

The present study was undertaken in order to describe the oral health status of children and adults in the Republic of Niger and to provide baseline data for the organisation and evaluation of systematic oral health promotion programmes in the country. The WHO pathfinder sampling procedures were applied to obtain representative samples of the following age groups: 6 years (n = 373); 12 years (n = 400); 18 years (n = 300) and 35-44 years (n = 400). Data were collected in 1997 according to the WHO methods, including information on dental caries and CPITN. In 6-year-olds, 56 per cent had caries and a mean score of 1.3 DMFT was observed among the 12-year-olds; the 35-44-year-olds had an average score of 5.7 DMFT. Differences in dental caries prevalence were found according to sex, province and urbanisation. Ninety-nine per cent of individuals at age 18, and 87 per cent at age 35-44 had maximum CPITN score 2 (calculus). Where 6- and 35-44-year-olds are concerned, the data may indicate increasing levels of dental caries. The implementation of primary prevention and community-based oral health education is therefore a matter of urgency.     

Oral health knowledge, attitudes and behaviour of adults in China

OBJECTIVES: To describe oral health behaviour, illness behaviour, oral health knowledge and attitudes among 35-44 and 65-74-year-old Chinese; to analyse the oral health behaviour profile of the two age groups in relation to province and urbanisation, and to assess the relative effect of socio-behavioural risk factors on dental caries experience. METHODS: A total number of 4,398 35-44-year-olds and 4,399 65-74-year-olds were selected by multistage stratified cluster random sampling which involved 11 provinces in China. Data were collected by self-administered structured questionnaires and clinical examinations (WHO criteria). RESULTS: 32% of the 35-44-year-olds and 23% of the 65-74-year-olds brushed at least twice a day but only 5% used fluoridated toothpaste; 30% and 17% respectively performed 'Love-Teeth-Day' recommended methods of tooth brushing. A dental visit within the previous 12 months was reported by 25% of all participants and 6% had a dental check-up during the past two years. Nearly 15% of the subjects would visit a dentist if they experienced bleeding from gums; about 60% of the subjects paid no attention to signs of caries if there was no pain. Two thirds of the urban residents and one fifth of the rural participants had economic support for their dental treatment from a third party, either totally or partially. Significant variations in oral health practices were found according to urbanisation and province. At age 35-44 years 43% of participants had daily consumption of sweets against 28% at age 65-74 years. Dental caries experience was affected by urbanisation, gender, frequency, time spent on and method of tooth brushing. Knowledge of causes and prevention of dental diseases was low with somewhat negative attitudes to prevention observed. CONCLUSION: Systematic community-based oral health promotion should be strengthened and preventive-oriented oral health care systems are needed, including promotion of further self-care practices and the use of fluoridated toothpaste.     

甘肃省口腔健康流行病学抽样调查报告

目的:了解并分析甘肃省城乡人群口腔健康状况,为口腔预防保健工作提供信息支持.方法: 按照第三次全国口腔健康流行病学调查标准和方法,采用多阶段分层等容量随机抽样方法对3 158 名5、12、35～44、 65～74 岁4 个年龄组的甘肃省城乡常住人口进行口腔健康调查.结果: 被调查的4 个年龄组患龋率分别为55.80%、19.09%、61.95%、78.63%,龋齿充填率3.11%、10.76%、10.34%、4.60%;12、35～44、65～74 岁组牙龈出血检出率82.81%、93.55%、85.34%,牙结石检出率69.66%、99.37%、92.54%;35～44岁、65～74 岁组牙周袋检出率60.94%、62.20%,口腔黏膜病检出率6.32%、7.71%,义齿修复情况以可摘局部义齿和非正规固定桥多见.结论: 甘肃省城乡人群龋病患病情况低于2005 年全国平均水平,多数年龄组比1995 年甘肃省结果明显降低,但牙周病患病情况严重且高于全国平均水平.     

An epidemiologic survey of oral health in Swaziland

An epidemiologic survey of oral health was conducted on 480 schoolchildren and 400 adults in Swaziland. Age groups 7, 14, 20-24 and 35-44 were selected, and nine sampling sites were chosen in various parts of the country. Oral hygiene was generally poor, visible soft deposits being prevalent in all age groups and calculus in adults. Advanced periodontal disease was present in most people over 35 years of age, and intense gingivitis was widespread in all age groups. Dental caries was found to be a common problem, affecting practically every person, in many cases quite severely. There was a tendency towards accumulation of the disease in children. Some geographic variation was found in the prevalence and severity of dental caries and periodontal disease. An additional sample of privileged children was examined, and among these children 14-year-olds showed significantly higher DMFS values than their age mates in the rest of the country. Tooth defects, including fluorosis, and oral mucosal diseases did not seem to constitute severe problems of oral health in Swaziland. On the basis of these data a public dental health program has been initiated which emphasizes prevention.     

Oral health in Slovenia, Yugoslavia

An oral health epidemiological survey using WHO assessment forms was conducted in the Republic of Slovenia (Yugoslavia) in 1987. The study population consisted of 1623 persons aged 6, 12, 15, 18, 35-44 and over 65 yr. The survey included 10 towns in 9 geographical areas of Slovenia. The results showed the prevalence of dental caries in the Slovenian population to be very high (93.6% in 12-yr-olds). The mean decayed, missing, and filled teeth (DMFT) scores were as follows: 5.1 at age 12 yr, 10.2 at 15 yr, 12.9 at 18 yr, 20.5 at 35-44 yr, and 27.0 in persons aged over 65 yr. Assessment of the periodontal status showed calculus to be the predominant disorder in the age groups 18 and 35-44 yr, while shallow pockets prevailed in persons aged over 65 yr.     

Oral health behaviour of children and adults in urban and rural areas of Burkina Faso, Africa

OBJECTIVES: To assess the level of dental knowledge and attitudes among 12 year-old children and 35-44 year-olds in Burkina Faso; to evaluate the pattern of oral health behaviour among these cohorts in relation to location, gender and social characteristics and; to evaluate the relative effect of social-behavioural risk factors on caries experience. DESIGN: Across sectional study including urban and rural subgroups of population. Sample and methods: Multistage cluster sampling of households in urban areas; in rural areas random samples of participants were based on the recent population census. The final study population covered two age groups: 12 years (n = 505) and 35-44 years (n = 493). RESULTS: For both children and adults, levels of oral health knowledge, attitudes and self-care were low; 36% of 12-year-olds and 57% of 35-44-year-olds carried out toothcleaning on a daily basis. Pain and discomfort from teeth were common while dental visits were infrequent. Tooth cleaning was mostly performed by use of chewsticks. Use of toothpaste was rare, particularly fluoridated toothpaste was seldom; 9% of 12-year-olds and 18% of 35-44-year-olds reported use of fluoride toothpaste. Significant differences were found in oral health knowledge, attitudes and practices according to location and gender. At age 12, important factors of high caries experience were location (urban), and consumption of soft drinks and fresh fruits. In 35-44-year-olds, gender (female), high education level, dental visit and occupation (government employee) were the significant factors of high dental caries experience whereas adults using traditional chewing sticks had lower DMFT. CONCLUSIONS: Health authorities should strengthen the implementation of oral disease prevention and health promotion programmes rather than traditional curative care. Community-oriented essential care and affordable fluoride toothpaste should be encouraged.     

Oral health in SFR Yugoslavia in 1986

A pilot oral health epidemiological survey using WHO assessment forms was conducted in Yugoslavia in the year 1986. The study population consisted of 2600 persons aged 6, 12, 15, 18, 35-44, and over 65 yr. The survey included 22 towns (11 developed and 11 underdeveloped) in the six Republics and two Provinces of Yugoslavia. The results showed the prevalence of dental caries in the Yugoslav population to be very high (98.7% in 12-yr-olds). The mean decayed, missing, and filled teeth (DMF) scores were as follows: 6.1 at age 12 yr, 9.6 at age 15, 10.9 at age 18, 18.0 at age 35-44, and 28.0 in persons aged over 65 yr. Assessment of the periodontal status showed calculus to be the predominant disorder in the age groups 18 and 35-44 yr, while loss of sextants prevailed in persons aged over 65 yr.     

Oral diseases and socio-economic status (SES)

OBJECTIVE: To determine the association between social, economic and behavioural risk factors and national prevalences of: oral cancer, dental caries (12-year-olds) and destructive periodontal disease (35-44-year-olds). DATA SOURCES: Sources for the social and economic parameters were the UN Development Program; the behavioural risk factors' source was the World Health Organization, the UN Food and Agricultural Organization and the World Atlas of History. Oral diseases data came from UICC Globocan and the World Health Organization databases. DATA EXTRACTION: Data were extracted by hand from official publications. DATA SYNTHESIS: Data were synthesized and analyzed in sequence using SPSS, Pearson's correlation coefficient and multiple regression analyses. CONCLUSIONS: There is a discernable association between the three oral diseases and the variables selected, which varies in strength, being strongest for chronic destructive periodontitis and weakest for oral cancer. Dental caries lies in between. The degree to which variables account for differences in the three oral diseases between the countries studied is striking, being insignificant for oral cancer incidence, modest for oral cancer mortality, stronger for dental caries and strongest for destructive periodontal disease. Removing variables with strong co-linearity with the Human Development Index has little effect on the regression coefficients.     

����ʡ35��74����Ⱥ������ȣ����������״���������鱨�棨2015—2016�꣩

?? Objective??To investigate the current status of caries on permanent teeth in a population of 35-74-year old in Liaoning Province??thus to provide scientific basis for the establishment of oral health care policies in Liaoning. Methods??An equal-sized stratified multi-stage random sampling design was applied to obtain representative sample groups consisting of 431 Liaoning residents each??aged 35 to 44??55 to 64 and 65 to 74 years old. The caries on the crowns and periodontal diseases of permanent teeth were assessed according to “the Guideline for the 4th National Oral Health Survey”??thereafter the prevalence of permanent teeth and the detectable rate of gingival bleeding and calculus were calculatedan and the difference was compared. Results??In these three groups ??the prevalence of crown caries was 72.7%??76.4% and 76.4%??and among them??only the urban-rural difference was statistically significant in the 35-44-year old group. The mean numbers of teeth affected by caries were 3.36??3.40 and 3.90??all groups being lower in cities than in rural areas??and the difference was statistically significant.The detection rate of gingival bleeding was 77.6%??78.5% and 68.1%??respectively??while the detection rate of calculus was 91.6%??93.1% and 88.2%??respectively.The mandibular anterior teeth were the most concentrated parts of the calculus. Conclusion??This survey shows that oral diseases ??especially dental caries and periodontal disease??are frequent and common in Liaoning province.Moreover??the treatment rate is very low??and primary pervention and treatment options are therefore urgently needed in this population.     

Dental caries trends in Africa

OBJECTIVES: To determine trends in published dental caries rates in Africa. METHODS: A systematic review of published information 1967-1997 was done on-line with the key words dental caries and the name of each of the 35 countries in sub-Saharan mainland Africa. For inclusion in the analysis WHO methods had to have been used for 5- to 6-, 11- to 13-, 14- to 15- and 35- to 44-year-old indigenous Africans. RESULTS: Of 327 papers published in the study period 69 were proper epidemiological studies and 45 fulfilled inclusion criteria. The groupings of caries prevalence and severity were evaluated. In two, significant declines in caries severity were seen for 5- to 6- and 35- to 44-year-olds. Of the remaining eight groupings there were non-significant decreases in five and increases in three. CONCLUSIONS: The study showed a predominantly downward trend in dental caries which was statistically significant for DMFT at age 5 to 6 years and for DMFT at 35 to 44 years.     

Oral health status and oral health behaviors in Chinese Children.

The objectives of the study were to describe the oral health status and treatment needs of the 5- to 6-year-old and 12-year-old children in Southern China; to describe the patterns of oral health behaviors, knowledge, and attitudes among the 12-year-olds; and to assess the effects of socio-behavioral factors on the 12-year-old children's dental caries experiences. The study sample was comprised of 1,587 5- to 6-year-old and 1,576 12-year-old urban and rural schoolchildren living in Guangdong Province. Three calibrated dentists clinically examined the children, and trained interviewers interviewed the 12-year-olds. Caries prevalence of the 5- to 6-year-old children was high (urban 78% vs. rural 86%); the mean dmft of the urban and rural children was 4.8 and 7.0, respectively. The caries prevalence and mean DMFT score of the 12-year-olds were 41% and 0.9 (urban) and 42% and 0.9 (rural). Only 2% of the 12-year-olds exhibited no calculus or gingival bleeding, while more than 70% had calculus. In conclusion, there is an urgent need for establishing caries-preventive activities for preschool children. The prevalence of caries among the 12-year-olds was not high, but their periodontal condition was unsatisfactory. Knowledge about gum bleeding and the use of fluoride was low. More oral health education activities should be organized, especially for the rural children.     

辽宁省35～74岁人群恒牙冠龋及牙龈疾病状况抽样调查报告（2015—2016年）

目的　了解辽宁省35～74岁人群恒牙冠龋及牙龈疾病状况,为辽宁省口腔健康保健工作及相关研究提供数据支持。方法　抽取辽宁省35～44岁、55～64岁、65～74岁常住居民共计431人,按照第四次全国口腔健康流行病学调查方案中临床牙列检查方法和标准,使用CPI探针检查全口恒牙冠龋及牙龈情况,计算恒牙冠龋患病率、龋均、牙龈出血率、牙石检出率,并比较存在的差异等。结果　辽宁省35～44岁、55～64岁、65～74岁人群恒牙冠龋患病率分别为72.7%、76.4%、76.4%,其中仅35～44岁年龄组城乡差异具有统计学意义（P < 0.05）;龋均分别为3.36、3.40、3.90,各年龄组城市均低于农村,差异具有统计学意义（P < 0.05）。牙龈出血检出率分别为77.6%、78.5%、68.1%,牙石检出率分别为91.6%、93.1%、88.2%,下颌前牙是牙石分布最为集中部位。结论　辽宁省中老年人群恒牙冠龋患病率、牙龈出血率及牙石检出率均较高,基础预防及治疗手段欠缺,有待进一步完善。     

东乡族、保安族、裕固族中年人口腔健康状况调查及相关知识行为分析

目的 调查东乡族、保安族和裕固族35~44岁中年人口腔健康状况及相关知识行为,为民族地区口腔疾病防治工作提供基础数据。方法 按照世界卫生组织以及第三次全国口腔健康流行病学调查的标准和方法,对东乡族、保安族和裕固族的445名35~44岁人群进行龋病及牙周健康检查,并对其口腔卫生行为、口腔保健知识及行为情况进行问卷调查。结果 1）东乡族、保安族、裕固族的冠龋患龋率分别为48.28%、79.47%、67.11%,根龋患龋率分别为38.62%、 69.54%、42.95%;2）东乡族、保安族、裕固族的牙龈出血率分别为86.90%、90.07%、65.77%,牙石检出率分别为99.31%、100.00%、99.33%,牙周袋检出率分别为68.97%、67.55%、43.62%。3）69.84%的人每天刷牙,94.90%的人很少或从不使用牙线;20.19%的人牙痛时会找医生治,42.23%的人从来没有看过牙病。结论 东乡族、保安族和裕固族中年人的患龋率高,牙周健康状况及口腔卫生差,口腔保健行为认知不足,应重视中年人龋病和牙周病的防治。     

Study on oral health status and health behavior of workers at government office]

The purpose of this study was to investigate the oral health status and health behavior of the adult population in the workplace. In 1998, oral health examination of 388 workers (male: 287, female: 101) at a government office was performed. A questionnaire was administered to obtain data regarding oral symptoms and health behavior. The results were as follows: Overall, 48% needed treatment for dental caries, 44% needed calculus removal, and 23% needed treatment for periodontal disease. Although there were no oral health complaints, 20% had early caries, 40% had dental calculus, and 19% had periodontitis. Compared to males, more females brushed their teeth, had home dentists (44%) and received more regular dental health check-ups at least once a year (48%). For males, those with home dentists had higher FT and DMFT in the twenties and thirties. There was no relationship between oral health status and regular check-ups in both males and females. The results revealed that receiving regular dental check-ups from home dentists was not popular in Japan. Further, the role of home dentists is not preventive oriented. It was concluded that it is necessary to provide regular oral health examination and health promotion programs for adult population at the workplace in Japan.     

The Fifth German Oral Health Study (Fünfte Deutsche Mundgesundheitsstudie,DMS V) – rationale,design, and methods

Background

Oral diseases rank among the most prevalent non-communicable diseases in modern societies. In Germany, oral epidemiological data show that both dental caries and periodontal diseases are highly prevalent, though significant improvements in oral health has been taking in the population within the last decades, particularly in children. It is, therefore, the aim of the Fifth German Oral Health Study (DMS V) to actualize the data on current oral health status and to gather information on oral health behavior and risk factors. In addition to current oral health monitoring, the study will also permit conclusions about trends in the development of oral health in Germany between 1989 and 2014.

Methods/Design

DMS V is a cross-sectional, multi-center, nationwide representative, socio-epidemiological study to investigate the oral health status und behavior of the German resident population in four age cohorts. Study participants are children (12-year-olds), adults (35- to 44-year-olds), young olds (65- to 74-year-olds), and old olds (75- to 100-year-olds) who are drawn from local residents’ registration offices. Social-science investigation parameters concern subjective perceptions and attitudes regarding oral health and nutrition, sense of coherence, and socio-demographic data. Clinical oral parameters are tooth loss, caries and periodontitis, prosthodontic status, further developmental and acquired dental hard tissue and mucosal lesions. To ensure reproducibility, the dental investigators are trained and calibrated by experts and multiple reliability checks are performed throughout the field phase. Statistical analyses are calculated according to a detailed statistical analysis plan.

Discussion

The DMS studies first performed in 1989, 1992 and repeated in 1997 and 2005 are the only cross-sectional oral health studies conducted in Germany on a population-based national representative level. Updated prevalence and trend analyses of key oral diseases are, therefore, of major epidemiological and health services research interest.

Trial registration

German Health Services Research Data Bank VfD_DMSV_13_002152

     

Evidence for dental caries decline among children in an East European country (Hungary)

In Central and Eastern Europe oral health systems are in transition due to the economic and political changes. The aim of the present study was to highlight the long-term trend in dental caries prevalence of Hungarian children. A WHO National Pathfinder Survey of oral health status was conducted in 1996 which included 6-year-olds (n = 900) and 12-year-olds (n = 900). Similar surveys were performed in 1985 (age 6-7, n = 895; age 12, n = 893) and in 1991 (age 5-6, n = 898; age 12, n = 898) and the surveys were based on the same sites and examination criteria. Clinical data were collected by trained dental examiners according to the WHO Basic Methods. In 1996, 73% of 5-6-year-olds and 84.5% of 12-year-olds were affected by dental caries. At age 5-6 the mean dmft was 4.5 and at age 12 the DMFT was 3.8. In both groups, the d/D-components were high (5-6 years: dt/dmft = 89%; 12 years: DT/DMFT = 45%). For children aged 5-6, the mean caries experience increased from 1991 (3.7 dmft) to 1996 (4.5 dmft) (P<0.01) whereas DMFT of 12-year-olds declined from 5.0 in 1985 and 4.3 in 1991 (P<0.01). The differences in caries experience by urbanization level were reduced over time. In 1996, 72% of 12-year-olds had gingival bleeding (CPI scores 1+2), and 23% had moderate/severe malocclusion. In conclusion, in order to meet the need for dental care in schoolchildren in Hungary health authorities are encouraged to revitalize the school dental services. Implementation of community-based health promotion is needed to control oral disease in Hungarian children.